Clinical Pain Abstracts:

Intended for personal use only; from The CFIDS Chronicle, published by the CFIDS Association of America, Inc. (800) 44-CFIDS, PO Box 220398 Charlotte, NC 28222-0398 where 923 (or like #) corresponds to year/edition #.

Subject: File: "CFIDS936 ASHENDOR"

The CFIDS Chronicle Physicians' Forum Fall 1993 Dr. Douglas Ashendorf

The Ability of Low Level Laser Therapy (LLLT) to Mitigate Fibromyalgic Pain

Douglas Ashendorf, MD, FAAPMR Newark, New Jersey

Most people are aware of high-powered lasers either in the context of a "Star Wars"-type weapon or as a surgical tool which burns and cuts tissue. Less well known is that low-energy lasers have been used internationally for decades to promote pain relief and wound healing.1 Research groups have also investigated laser application for nerve injury2 and rheumatoid arthritis.3 No published study to date has specifically tested the value of laser treatment in fibromyalgia or CFIDS (chronic fatigue and immune dysfunction syndrome).

Most of the modalities used in physical therapy, including moist heat, ultrasound and short wave diathermy, derive their benefit from a thermal (heating) effect upon tissues. Low level laser therapy (LLLT), on the other hand, causes virtually no thermal effect and therefore works via entirely different mechanisms.4 The laser appears to have diverse and significant effects on cells and cell functions, including reparative processes5 and neurotransmitter release.6 Clinically, this may be expressed as an enhancement of wound healing and nerve repair, as an anti-inflammatory and as an analgesic.

There are several reasons why the laser has never achieved popularity in the practice of medicine in the United States. Because much of the early work in this field was done in Hungary and the USSR, information was slow in reaching the more established and widely read journals. Second, as in trials of any modality or treatment for a painful or other "subjective" condition, there have been the inherent difficulties of defining diagnoses, determining magnitude and establishing valid measurement tools and outcome criteria. Third, past studies have used different types of lasers and different exposure lengths, intensities and sites, making comparisons difficult.

In the U.S., the laser is considered an investigational "Non- Significant Risk Device" by the Food and Drug Administration (FDA) and can only be sold to practitioners who are members of an Institutional Review Board (IRB) with an established research protocol.7 The only known safety concern is to the eyes, and this is obviated by the use of OSHA-approved goggles for both the practitioner and the patient.

Pilot Study In my office, a pilot study is underway in which the laser is used to treat patients who meet the American College of Rheumatology (ARC) criteria for fibromyalgia: widespread pain and tenderness in at least 11 of 18 (specified) bilateral locations.9 In addition, most of the cases met many of the so-called "minor criteria" including generalized fatigue, chronic headache, sleep disturbance, anxiety, subjective swelling, numbness, irritable bowel/bladder and modulation of symptoms by activity, weather and stress.5 Only a few patients met both the ARC criteria for fibromyalgia and the Centers for Disease Control (CDC) criteria for chronic fatigue syndrome.10

Patients in the LLLT/fibromyalgia study generally receive treatment five days per week for three weeks and 1 to 2 days per week for another month. No patient has yet been tapered entirely. If no response to therapy is observed in 2 to 3 weeks, the patient appears unlikely ever to benefit, and has left the study. All patients were also involved in a comprehensive stretching program11 at home and/or in our clinic. All patients had already undergone trials of low-dose antidepressants. Some had undergone trigger point injection therapy and/or various neurolytic (nerve blocking) procedures. In all cases, there was uniform patient dissatisfaction with the results of prior treatment.

Side Effects Are Limited Side effects of laser therapy encountered include brief episodes of the following: anxiety, dizziness, nausea, headache and sedation. In only one case did a patient find this objectionable enough to leave the study; in all other cases the frequency, intensity and duration of side effects decreased with time. There is no sensation associated with laser treatment, per se; all side effects occurred sometime after a treatment session began, or a short time after it ended.

Promising Results Thus far, results have suggested that the pain relieving properties of LLLT have been the most consistent benefit. The duration of benefit has varied from one hour to one week, and seems to increase as treatment progresses. In no case has pain relief been permanent. Other areas of improvement were not as clear. Improvement in sleep was observed with some regularity although this was undoubtedly due in part to decreased pain. The "non-restorative" sleep complaints were less regularly improved. Improvement with regard to abnormal sensations in the limbs (paresthesia and subjective swelling) appears to be fairly consistent. Improvements in fatigue, mood and headache have been irregular. Immune function could not be assessed due to the relatively small number of patients so affected.

Future Plans Cooperation between investigators, including a shared database and standardized treatment protocols, will be necessary to determine whether laser therapy should ultimately become a permanent part of our treatment for fibromyalgia. The use of laser therapy on patients meeting the CDC criteria for CFIDS has yet to be explored.

Other diagnostic groups are also being treated with LLLT outside of the fibromyalgia pilot study, including: myofascial pain syndrome, nerve root irritation from herniated discs and arthritis (discogenic and vertebrogenic radiculopathy), facet joint syndrome, refle xsympathetic dystrophy, bursitis, tendonitis, acute ligamentous strains, chondromalacia patella, carpel tunnel syndrome and migraine headache disorder. Rheumatoid arthritis and diabetic neuropathy will soon be added

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LLLT_musculoskeletal abstracts

LLLT_Clinical pain abstracts

LLLT Wound pictures